Spinal Fracture Types: Causes, Symptoms, and Treatment

A spinal fracture is a break in one or more bones of the spine. It can range from a stable osteoporotic compression fracture to a severe traumatic injury that threatens the spinal cord or nerves. The seriousness depends on the fracture location, stability, degree of bone displacement, and whether the spinal cord, cauda equina, or nerve roots are involved. Any suspected spinal injury after trauma should be treated as urgent until assessed by a doctor.
 

Seek Emergency Care Immediately If:

• There is severe neck or back pain after a fall, accident, or diving injury
• There is weakness, numbness, tingling, or paralysis in any limb
• The person cannot walk or stand after an injury
• There is loss of bladder or bowel control, difficulty passing urine, or numbness around the groin or saddle area
• There is visible spinal deformity or the neck is held in an abnormal position
• A person with known cancer develops new, severe, progressive, or night-time back pain
• An older adult, someone with osteoporosis, or someone taking steroids or blood thinners develops new back pain after a fall

If a spinal injury is suspected after trauma, keep the person still and avoid moving the neck or back unless there is immediate danger. Call emergency services.
 

Understanding the Spine

The spine is made of vertebrae arranged in five regions. The cervical spine has seven neck vertebrae, and injuries here can affect arm and leg movement; in high cervical injuries, breathing may also be affected. The thoracic spine has twelve mid-back vertebrae attached to the rib cage. The lumbar spine has five lower-back vertebrae that carry much of the body's weight. The sacrum consists of fused vertebrae forming the back of the pelvis and is associated with pelvic injuries in highnergy trauma. The coccyx is the tailbone; it is painful when fractured but is rarely associated with spinal cord injury.

The spinal cord runs through the spinal canal and usually ends around the first to second lumbar vertebra. Below this level, a bundle of nerve roots called the cauda equina continues downward, supplying the legs, bladder, bowel, and sexual function. Loss of bladder or bowel control, or numbness in the saddle area, may indicate injury to the cauda equina and is a medical emergency.
 

Stable vs Unstable: The Key Distinction

A stable fracture means the spine is unlikely to shift further under usual protected movement, and the spinal cord or nerves are not at immediate risk. An unstable fracture means the spine's supporting structures are disrupted, and movement could worsen bone displacement or cause neurological injury.

Stability is determined by clinical examination and imaging, including CT and sometimes MRI. Pain severity alone does not determine stability, and a person cannot judge stability from how they feel. After trauma, the person should be kept still and emergency medical care sought until spinal injury is properly excluded.
 

What Causes Spinal Fractures?

Highnergy Trauma

Road traffic accidents, falls from height, diving injuries, contact sports, and industrial accidents generate sudden high-force loading of the spine. These create compression, flexion, rotation, and distraction forces that can damage multiple vertebral components, spinal ligaments, and intervertebral discs. The thoracolumbar junction, where the relatively rigid thoracic spine meets the mobile lumbar spine, is a frequently affected zone.

A person with a suspected traumatic spinal injury should not be made to sit, stand, or walk until evaluated by a trauma or spine team. These injuries should be treated as potentially unstable until assessed.
 

Osteoporosis and Fragility Fractures

Osteoporosis reduces bone density and structural integrity until vertebrae can fracture under forces that would not affect healthy bone. These osteoporotic vertebral compression fractures may occur after bending forward, coughing, lifting something light, turning in bed, or a minor fall. They are common in older adults and postmenopausal women, and also in people who take long-term steroids, have had previous fragility fractures, have low body weight, have limited sun exposure, or have other conditions affecting bone health.

A vertebral fragility fracture is a sentinel event that should prompt evaluation for osteoporosis and assessment of future fracture risk. Treatment of the underlying bone disease and fall-prevention measures are as important as treating the fracture itself.
 

Cancer and Pathological Fractures

A pathological fracture occurs when bone is weakened by disease. Metastatic cancer, multiple myeloma, and spinal infection can all cause vertebral collapse. Cancers that commonly spread to bone include breast, prostate, lung, kidney, and thyroid cancers.

A person with current or previous cancer should seek urgent medical advice for new, progressive, severe, or night-time back pain. Weakness, numbness, difficulty walking, bladder or bowel changes, or pain radiating around the chest or down the legs may suggest spinal cord or nerve compression and should be treated as a medical emergency. Delayed recognition of metastatic spinal cord compression can result in permanent paralysis.
 

Stress Injuries and Spondylolysis

Repeated spinal loading, particularly lumbar extension and rotation, can cause a stress reaction or fracture at the pars interarticularis, most often at the fifth lumbar vertebra. This is called spondylolysis. It is seen in young athletes including fast bowlers in cricket, gymnasts, footballers, and weightlifters. Most cases improve with activity modification, physiotherapy, core strengthening, and gradual return to sport. If one vertebra slips forward on another due to the pars defect, this is called spondylolisthesis.
 

Types of Spinal Fractures

Spinal fractures are classified by location, fracture pattern, stability, neurological involvement, and cause. The following describes the main fracture types encountered in clinical practice.
 

Compression Fracture

A compression fracture occurs when the vertebral body collapses, usually more at the front than the back, creating a wedge shape. It is common in osteoporosis but may also occur after significant trauma in people with healthy bone. In a simple stable compression fracture, the posterior wall and ligaments remain intact and the spinal canal is preserved. Neurological complications are uncommon with isolated stable compression fractures, though they should not be assumed absent without clinical assessment.

Multiple vertebral compression fractures cause progressive loss of height and forward curvature of the upper back, called kyphosis. The term dowager's hump is outdated and should not be used.
 

Burst Fracture

A burst fracture occurs when a high-force axial load causes the vertebral body to break in multiple directions. Bone fragments may move backwards into the spinal canal, potentially compressing the spinal cord or nerve roots. Burst fractures most often occur at the thoracolumbar junction.

Treatment depends on neurological status, fracture stability, spinal alignment, degree of canal compromise, and associated ligament injury. Some stable burst fractures can be treated with bracing; unstable fractures or those associated with neurological compromise may require surgery.
 

Flexion-Distraction Injury and Chance Fracture

A flexion-distraction injury occurs when the spine bends forward and is simultaneously pulled apart. It classically occurs in lap-belt injuries during sudden deceleration in road accidents. These injuries may involve bone, ligaments, or both and can be unstable. They are also associated with abdominal injuries, including bowel injury, which should be actively assessed. Treatment depends on whether the injury is predominantly bony or ligamentous; selected stable bony injuries may be managed with bracing, while unstable or ligamentous injuries typically require surgery.
 

Fracture-Dislocation

A fracture-dislocation is a severe injury in which one vertebra fractures and shifts out of alignment with another. It usually results from highnergy trauma and is often unstable, with a high risk of spinal cord or nerve damage. Emergency immobilisation, full trauma assessment, CT and MRI, and urgent spine specialist review are required. Surgery is commonly needed to decompress nerves, restore alignment, and stabilise the spine, though timing depends on the person's overall clinical condition and haemodynamic stability.
 

Osteoporotic Vertebral Compression Fracture

As described above, these fractures may occur after a minor movement or low-height fall and sometimes without any clear trigger. Pain is typically localised to the fracture level, worsened by standing or walking, and relieved by lying down. Most stable fractures improve over weeks to months with conservative management, but medical evaluation is important to confirm the diagnosis, assess stability, manage pain safely, and initiate osteoporosis treatment to reduce the risk of further fractures.
 

Spondylolysis and Spondylolisthesis

Spondylolysis is a stress injury or fracture of the pars interarticularis, most often at L5. It may cause lower back pain worsened by extension activities, running, bowling, gymnastics, or heavy lifting. Most low-grade cases are managed conservatively. If the vertebra slips forward, it is called spondylolisthesis, graded by degree of displacement. Low-grade slips are usually managed non-operatively. High-grade slips, progressive deformity, neurological symptoms, or bladder and bowel symptoms require specialist assessment and may need surgery.
 

Transverse and Spinous Process Fractures

These fractures involve the bony projections where muscles and ligaments attach. Isolated fractures of these processes are usually stable and treated with pain management and gradual mobilisation. However, multiple lumbar transverse process fractures can indicate highnergy trauma and should prompt assessment for associated kidney, abdominal, retroperitoneal, pelvic, or vascular injury.
 

Cervical Spine Fractures

Cervical spine fractures involve the neck vertebrae and may threaten the spinal cord. Suspected cervical injury after any trauma requires immobilisation and emergency assessment. Common types include the Jefferson fracture, which is a burst fracture of the first cervical vertebra caused by axial loading such as a diving injury; the odontoid fracture, which involves the bony peg of the second cervical vertebra and is common in older adults after falls; the Hangman's fracture, which is a traumatic injury involving bilateral pars fractures of the second cervical vertebra; and subaxial cervical fractures from the third to seventh vertebra, which include compression fractures, facet dislocations, and flexion teardrop injuries. Flexion teardrop injuries are often unstable and may be associated with spinal cord injury.
 

Symptoms of a Spinal Fracture

Symptoms depend on the fracture location, stability, and degree of nerve involvement.

Common symptoms include sudden neck or back pain after trauma; localised tenderness over the spine; pain that worsens with standing, walking, coughing, or movement; pain that improves with lying down; reduced height or increasing forward bend of the back over time in older adults; and pain radiating around the chest, abdomen, buttocks, arms, or legs.

The following symptoms require emergency assessment:

• Weakness, numbness, or tingling in any limb
• Difficulty walking, unsteady gait, or inability to stand
• Loss of bladder or bowel control, or inability to pass urine
• Numbness in the saddle area, groin, or inner thighs
• Severe neck or back pain following trauma, diving, or a fall
• Visible deformity of the spine
• New severe, progressive, or night-time back pain in a person with known or suspected cancer
   

How Are Spinal Fractures Diagnosed?

Diagnosis combines clinical examination, neurological assessment, and imaging. The appropriate imaging depends on the mechanism, clinical findings, and degree of suspicion for serious injury.

X-ray may identify vertebral height loss or deformity, particularly in suspected thoracic or lumbar fractures without neurological signs or highnergy mechanism. However, a normal X-ray does not exclude a fracture, and X-ray is not always the appropriate first investigation.

CT scan is best for defining bony injury, fracture pattern, canal narrowing, and posterior element involvement. In adult cervical trauma, major trauma, or when clinical suspicion of significant injury is high, CT is often used as the primary investigation rather than X-ray. CT is also used when X-ray findings are abnormal or clinical concern remains after normal X-ray.

MRI is best for assessing the spinal cord, nerve roots, intervertebral discs, ligaments, bone marrow changes, and for distinguishing acute from older fractures. It is essential when neurological symptoms are present and is also used to evaluate suspected infection, cancer, or cord compression.

DEXA scan measures bone mineral density and is used after fragility fractures to assess osteoporosis and guide treatment.

Additional investigations including blood tests, cancer staging work-up, infection markers, or in selected cases a biopsy of a vertebral lesion may be needed when a pathological fracture from cancer or infection is suspected.
 

Treatment

Conservative Treatment

Stable fractures without neurological compromise are often treated without surgery. Management may include a short period of activity modification, avoiding prolonged bed rest where possible; pain relief appropriate to the individual's age, kidney function, gastrointestinal risk, and other medications; a brace or collar when advised by the spine specialist to restrict movement during healing; supervised physiotherapy after the acute phase; fall-prevention measures, balance training, and review of medicines that increase fall or bone-loss risk in older adults; and evaluation and treatment of underlying osteoporosis following a fragility fracture.

Pain medicines should be chosen carefully, particularly in older adults. Non-steroidal anti-inflammatory drugs carry risks in elderly patients, those with kidney disease, those taking anticoagulants, and those with gastric ulcer history. Opioids require careful dose selection and monitoring. Medication choices should be guided by the treating clinician.

Osteoporosis Treatment After Fragility Fracture

A vertebral fragility fracture indicates substantially increased risk of future fractures and should trigger formal osteoporosis assessment and treatment. Bone-strengthening medications are selected based on fracture risk, prior fracture history, bone mineral density, and individual medical factors. Bisphosphonates are commonly used as first-line treatment for many high-risk patients. Denosumab is an alternative but should not be discontinued without a plan to transition to another treatment, as stopping it abruptly may cause rapid bone loss and fracture risk rebound. Anabolic agents such as teriparatide or romosozumab may be considered in selected very-high-risk patients, and romosozumab has specific cardiovascular cautions that require assessment. Calcium and vitamin D intake should be assessed and optimised through diet or supplementation where intake or levels are inadequate. These decisions should be made with the treating specialist.

Vertebroplasty and Kyphoplasty

Vertebroplasty and kyphoplasty are image-guided procedures in which medical cement is injected into a painful collapsed vertebra. In kyphoplasty, a balloon is inflated first to create space and may partly restore vertebral height before cement is placed. These procedures are not needed for most osteoporotic compression fractures, which improve with conservative management.

These procedures may be considered in selected patients who have severe ongoing pain from a recent unhealed osteoporotic fracture despite adequate pain management, when clinical examination and imaging confirm the pain originates from that specific fracture. They are not appropriate as a routine or early treatment.

Potential risks include cement leakage into the spinal canal or blood vessels, nerve compression, infection, bleeding, pulmonary embolism, adjacent vertebral fracture, and persistent pain. These risks should be discussed with the treating specialist before the procedure.

Surgery

Surgery may be needed for unstable fractures, spinal cord or nerve compression, progressive deformity, fractures causing unacceptable pain not controlled by other means, or pathological fractures requiring stabilisation.

Surgical approaches vary depending on the fracture type and location and may include decompression of the spinal cord or nerve roots, pedicle screw fixation, spinal fusion, anterior vertebral reconstruction, or in selected cervical injuries, external immobilisation such as a halo vest. Many stabilisation procedures are now performed using minimally invasive techniques.

Surgical risks include infection, bleeding, injury to nerves or the spinal cord, cerebrospinal fluid leak, implant failure, non-union, persistent pain, and the need for revision surgery. Anaesthetic risks should also be discussed. In cancer-related fractures, treatment planning involves spine surgery, oncology, radiation oncology, and rehabilitation teams working together.

Recovery

Recovery depends on fracture type, stability, neurological status, treatment method, age, bone quality, and overall health. Many stable compression fractures improve significantly within four to eight weeks, though full recovery may take several months. Surgery may allow earlier stabilisation, but healing and rehabilitation still require time.

Follow-up after spinal fracture typically includes repeat imaging at appropriate intervals, brace review and adjustment if applicable, physiotherapy and rehabilitation, osteoporosis treatment review, and planning for return to work, sport, or daily activity.

In people with significant neurological injury, recovery involves management of bladder and bowel function, pressure injury prevention, prevention of deep vein thrombosis, respiratory care, and psychological support alongside physical rehabilitation.

Seek urgent review during recovery if pain suddenly worsens significantly, new weakness or numbness develops, walking becomes more difficult, bladder or bowel symptoms occur, fever develops, or a surgical wound becomes red, swollen, or discharging.
 

Frequently Asked Questions

What is the most common type of spinal fracture?

Vertebral compression fractures related to osteoporosis are among the most common spinal fractures, particularly in older adults. They may be missed because the pain is often attributed to muscle strain or age-related back ache. New localised back pain in an older adult or someone at risk of osteoporosis warrants medical evaluation.

Can a spinal fracture heal without surgery?

Many stable spinal fractures heal without surgery when the spinal cord and nerves are not at risk. Treatment may include pain control, a brace when advised, physiotherapy, and follow-up imaging to confirm healing. Surgery is considered when the fracture is unstable, causes nerve compression, leads to progressive deformity, or produces pain not controlled by other means. Medical evaluation is needed to determine which approach is appropriate.

How do I know if back pain is a fracture or muscle strain?

You cannot reliably distinguish a fracture from a muscle strain based on pain alone. Seek medical evaluation if back pain follows trauma, occurs after a fall in an older adult, is associated with osteoporosis or long-term steroid use, occurs in someone with cancer, is severe or worsening, wakes you from sleep, or is accompanied by weakness, numbness, fever, unexplained weight loss, or bladder and bowel symptoms.

Is a burst fracture always serious?

A burst fracture is more complex than a simple compression fracture, but severity varies considerably. Doctors assess neurological status, canal compromise, ligament integrity, spinal alignment, and fracture stability. Some stable burst fractures with no neurological deficit can be managed with bracing. Others with instability or nerve compression require surgery.

Can osteoporosis cause a spinal fracture without a fall?

Yes. In osteoporosis, a vertebra may fracture after bending, coughing, lifting, turning in bed, or a minor fall. New localised back pain in an older adult or someone at risk of osteoporosis should be medically evaluated. If a fragility fracture is confirmed, osteoporosis treatment should be initiated to reduce the risk of further fractures.

What is the difference between vertebroplasty and kyphoplasty?

Both procedures inject medical cement into a painful collapsed vertebra. Kyphoplasty uses a balloon first to create space and may partly restore vertebral height before cement is placed. These procedures are considered only in selected patients with severe ongoing pain from a recent unhealed osteoporotic fracture despite optimal pain treatment. They are not routine first-line treatments. Risks include cement leakage, infection, bleeding, nerve injury, and adjacent fracture.

How long does a spinal fracture take to heal?

Many stable fractures improve significantly within four to eight weeks, but full recovery may take several months. Healing may take longer with osteoporosis, diabetes, smoking, long-term steroid use, cancer-related fractures, infection, or unstable injuries. Follow-up with the treating spine team, repeat imaging when indicated, and treatment of underlying conditions affecting bone health are all important parts of recovery.

When should I be worried about back pain in cancer?

Anyone with a history of cancer who develops new, severe, progressive, or night-time back pain should seek urgent medical assessment. Pain radiating around the chest or down the legs, weakness, numbness, difficulty walking, or any change in bladder or bowel function in a cancer patient may indicate spinal cord or nerve root compression, which is a medical emergency. Prompt assessment and treatment significantly affect outcomes.

Key Takeaways

• Spinal fractures vary from stable osteoporotic compression fractures to severe unstable injuries with spinal cord risk. Stability and neurological involvement are the most important factors guiding treatment.
• After trauma, keep the person still and do not move the neck or back unless there is immediate danger. Call emergency services. Suspected spinal injury should be treated as unstable until assessed.
• Weakness, numbness, difficulty walking, loss of bladder or bowel control, saddle numbness, or severe neck and back pain after trauma are emergency symptoms requiring immediate medical care.
• New severe, progressive, or night-time back pain in a person with known or suspected cancer should be urgently assessed. Neurological symptoms in cancer patients may indicate cord compression, which is a medical emergency.
• Osteoporotic vertebral fractures are common and often missed. They should trigger evaluation and treatment for osteoporosis and fall-prevention measures to reduce future fracture risk.
• CT is often the first imaging investigation in significant trauma, not X-ray. MRI is required when neurological symptoms are present or soft tissue and cord assessment is needed.
• Vertebroplasty and kyphoplasty are procedures for selected patients with severe ongoing pain from recent unhealed osteoporotic fractures despite optimal pain management. They are not routine treatments.
• Osteoporosis medications require individualised selection. Denosumab should not be stopped without a transition plan, and romosozumab has cardiovascular cautions that must be assessed.